Symptoms of anxiety and depression and their relationship with barriers to physical activity in patients with intermittent claudication

OBJECTIVES: Although the practice of physical exercise in patients with intermittent claudication (IC) is often encouraged, adherence is low. The difficulty in performing physical training may be related to the psychological characteristics of patients with claudication. To verify the association between anxiety and depression symptoms and barriers to physical exercise and walking capacity in patients with IC. METHODS: One-hundred and thirteen patients with a clinical diagnosis of IC were included in the study. Patients underwent clinical evaluation by a vascular surgeon, answered the Beck Depression Inventory, and Beck Anxiety Inventory tests were applied by the psychologist. The patients performed the 6-minute test and reported their barriers to physical activity practice in a questionnaire. RESULTS: Patients with signs of depression had a shorter pain-free walking distance (p=0.015) and total walking distance (p=0.035) compared to patients with no signs of depression. Pain-free walking distance (p=0.29) and total walking distance (p=0.07) were similar between patients with and without signs of anxiety. Patients with symptoms of moderate to severe depression reported more barriers to physical activity practice compared to patients without signs of depression. CONCLUSION: Symptoms of anxiety and depression are prevalent among patients with peripheral arterial occlusive disease (PAD). Depression symptoms are associated with personal barriers to exercise, while anxiety symptoms are not. The main barriers to physical activity among patients with IC are exercise-induced pain and the presence of other diseases

Symptoms of anxiety and depression and its relation with physical activity and barriers in patients with intermittent claudication

Introdução: A claudicação intermitente (CI) dos membros inferiores é causada pelo desbalanço entre a demanda e a oferta de oxigênio que ocorrem em consequência à isquemia muscular produzida pelo exercício nos pacientes em estágio inicial da doença arterial crônica periférica. O tratamento da claudicação é baseado no controle dos fatores de risco e atividade física. Embora a prática do exercício físico seja frequentemente encorajada, a aderência especialmente em pacientes idosos e claudicantes é baixa. Está bem estabelecida a relação de bidirecionalidade entre depressão e a doença vascular. Esses indivíduos sintomáticos apresentam uma baixa performance nos testes de esteira e diminuição significativa nas distâncias livre de dor e total de caminhada. A ansiedade apresenta relação prognóstica negativa especialmente em pacientes coronariopatas. A dificuldade em realizar o treinamento físico caracterizada pelas barreiras pode estar relacionada às características psicológicas do paciente claudicante. Objetivo: Verificar a prevalência de sintomas de ansiedade e depressão nos pacientes com diagnóstico de claudicação intermitente, determinar a associação entre os sintomas de ansiedade e depressão e a distância livre de dor durante a caminhada e distância total de caminhada; determinar qual barreira à caminhada é a mais prevalente relacionado-as com os fatores psicológicos. Método: No ambulatório de claudicação intermitente do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, foram incluídos 113 pacientes com diagnóstico clínico de CI, no período de fevereiro de 2014 a dezembro de 2016, segundo protocolo pré-estabelecido após a aprovação da Comissão de Ética para Análise de Projetos de Pesquisa e assinatura do termo de consentimento livre e esclarecido. Os pacientes incluídos foram submetidos a avaliação pelo cirurgião vascular, realizada a anamnese o exame vascular completo, foram aplicados os testes Inventário de Depressão de Beck (BDI) e Inventário de ansiedade de Beck (BAI) pela psicóloga e a realização do Teste de 6 minutos de caminhada com educadores físicos. Em uma segunda consulta ambulatorial foi aplicado o questionário de barreiras pessoais. Resultados: Os pacientes com sinais de depressão apresentaram menor distância livre de dor (119 ± 63 m vs. 159 ± 87 m, P=0,015) e menor distância total de caminhada (313 ± 71 m vs. 347 ± 71 m, P=0,035) em comparação aos pacientes sem sinal de depressão. A distância livre de dor (129 ± 71 m vs. 148 ± 84 m, P=0,29) e a distância total de caminhada (309 ± 85 m vs. 343 ± 84 m, P=0,07) foram similares entre os pacientes com e sem sinal de ansiedade. As barreiras mais frequentes nos pacientes com sintomas de depressão leve são: dor induzida pelo exercício, falta de energia, ter outra doença ou incapacidade e o medo de cair ou agravar a doença. As barreiras mais frequentes nos pacientes com sintomas de depressão moderado a grave foram: falta de energia, não ter companhia para praticar atividade física, falta de dinheiro, falta de conhecimento ou incerteza sobre os benefícios da prática de atividade física e o medo de cair ou agravar a doença. Conclusão: A prevalência de ansiedade e depressão nos pacientes claudicantes é alta e precisam ser acompanhados de perto na prática clínica e triados para alterações do humor, especialmente os sintomas de depressão pois estão associados à significativa piora da função em pacientes com DAOP. O tratamento para os sintomas depressivos poderia melhorar a função dos pacientes com DAOP, em nosso conhecimento essa hipótese ainda não foi testada.Introduction: Intermittent claudication (IC) of the lower limbs is caused by the imbalance between demand and supply of oxygen that occur as a consequence of exercise-induced muscle ischemia in patients with early stage peripheral chronic arterial disease. The treatment of IC is based on the control of risk factors and physical activity. Although the practice of physical exercise is often encouraged, adherence especially in elderly patients is low. The bidirectional relationship between depression and vascular disease is well established. These symptomatic individuals present poor performance on treadmill tests and a significant decrease in pain-free and total walk distances. Anxiety presents a negative prognostic relationship especially in coronary patients. The difficulty in performing the physical training characterized by the barriers may be related to the psychological characteristics of the claudicating patients. Objective: The objectives are: to verify the prevalence of anxiety and depression symptoms in patients diagnosed with intermittent claudication, to determine the association between anxiety and depression symptoms and pain-free distance during walking and total walking distance; determine which barrier to walking is the most prevalent related to psychological factors. Method: In the period from February 2014 to December 2016 at Clinical Hospital of the Faculty of Medicine of the University of São Paulo, 113 patients with a clinical diagnosis of IC were included in the study, according to a protocol pre-established after approval of the Ethics Committee for Analysis of Research Projects and signing of the free and informed consent term. Patients included underwent evaluation by the vascular surgeon, anamnesis and complete vascular examination, the Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI) tests were applied by the psychologist and the 6-minute Test with physical educators. The personal barriers questionnaire was applied in a second outpatient visit. Results: Patients with signs of depression had a lower pain-free distance (119 ± 63 m vs. 159 ± 87 m, P = 0.015) and shorter walking distance (313 ± 71 m vs. 347 ± 71 m, P = 0.035) compared to patients with no sign of depression. Pain free distance (129 ± 71 m vs. 148 ± 84 m, P = 0.29) and total walking distance (309 ± 85 m vs. 343 ± 84 m, P = 0.07) were similar between patients with and without anxiety. The most frequent barriers in patients with symptoms of mild depression are: pain induced by exercise, lack of energy, having another illness or disability and fear of falling or aggravating the disease. The most frequent barriers in patients with symptoms of moderate to severe depression were: lack of energy, lack of companionship to practice physical activity, lack of money, lack of knowledge or uncertainty about the benefits of practicing physical activity and the fear of falling or aggravate the disease. Conclusion: The prevalence of anxiety and depression in claudicating patients is high. This individuals need to be closely monitored in clinical practice and screened for mood disorders, especially the symptoms of depression because they are associated with significant worsening of function in patients with PAOD. Although the treatment for depressive symptoms could improve the function of patients with PAD, to our knowledge this hypothesis has not yet been tested

Prevalence of Metabolic Syndrome in Patients With Intermittent Claudication and its Correlation With the Segment of Arterial Obstruction

The metabolic syndrome (MetS) is associated with increased cardiovascular morbidity and mortality. Intermittent claudication reflects the presence of peripheral arterial disease (PAD). The aim of this study is to determine the prevalence of the MetS in claudicants and its correlation with age, gender, localization of arterial obstruction, and symptomatic coronary disease. Patients (n = 170) with intermittent claudication were studied. The mean age was 65 years (33-89). Metabolic syndrome was diagnosed in 98 patients (57.6%). The mean age of patients with MetS was 63.5 years compared with 67.0 years for patients without MetS (P = .027). Considering patients aged >= 65 years, MetS was present in 46 (48.9%) individuals and in 52 (68.4%) patients younger than 65 years (P = .011). Metabolic syndrome must be actively searched for in claudicant patients

Comparação entre os métodos subjetivo e objetivo para avaliação da capacidade funcional durante tratamento clínico em pacientes com claudicação intermitente

OBJETIVO: Verificar se há relação entre a medida da capacidade funcional avaliada subjetiva e objetivamente em relação ao estado atual e após tratamento clínico em pacientes com claudicação intermitente. MÉTODOS: Foram recrutados 500 pacientes com claudicação intermitente. Todos realizaram exame clínico e foram submetidos a uma avaliação funcional por meio do método subjetivo (consulta clínica) e objetivo (teste de esteira). Adicionalmente, 50 pacientes foram selecionados para se avaliar o efeito do tratamento clínico, pelos métodos subjetivo e objetivo, em relação à capacidade funcional. RESULTADOS: Dos 500 pacientes selecionados, somente 60 (12,0%) apresentaram valores referidos e observados similares. Os demais pacientes, ou seja, 440 (88,0%) apresentaram valores relatados discordantes em relação àqueles obtidos no teste de esforço. Com relação ao efeito do tratamento clínico em relação à capacidade funcional, os resultados foram similares entre ambos os métodos (χ²=1,7; p=0,427). CONCLUSÃO: Apesar de o método subjetivo superestimar os valores de capacidade funcional, quando comparados ao método objetivo, não foram observadas diferenças significantes entre ambos os métodos, quando se analisou o efeito do tratamento clínico. Assim, o método subjetivo fornece informações similares em comparação à medida objetiva no acompanhamento do tratamento clínico de pacientes com claudicação intermitente

Symptomatic uterine leiomyomatosis with intracaval and intracardiac invasion: Video case report

Background: Fibroid is the most prevalent benign tumor of the female genital tract. Intravenous and intracardiac leiomyomatosis (IVL and ICLM, respectively) are rare complications that present with symptoms of pulmonary thromboembolism and heart failure and whose etiology, despite controversial, is a direct vascular invasion by a primary uterine leiomyoma. Case presentation: We present the case of a 31-year-old female patient with a previous history of pelvic pain and dysmenorrhea, whose ultrasound showed an enlarged and heterogeneous uterus. Complete hysterectomy was performed, and the anatomopathological examination showed leiomyomas without evidence of malignancy. One month later, the patient manifested dyspnea and chest pain. A neoplastic thrombus was identified, extending from the inferior vena cava to the right atrium, for which we proceeded with cavo-atrial thrombectomy under Normothermic Cardiopulmonary Bypass (CPB) with Warm Blood Cardioplegia (WBC). A metastatic lung injury of non-malignant histology was also detected. Discussion: Uterine leiomyoma is a very common benign tumor of the female genital tract. IVL with ICLM are rare and difficult-to-treat complications, whose etiology is a direct vascular invasion by a primary uterine leiomyoma, although it is still controversial. The incidence of ICLM is 10 to 30% of IVL cases. The main symptoms of ICLM are dyspnea, syncope, edema of the lower extremities and palpitations. Treatment is based on complete surgical removal of the tumor thrombus. Studies demonstrated that the one-stage procedure is safer from the patient’s perspective and that CPB with WBC reduced intraoperative blood loss and total operative time, ensuring a less traumatic postoperative. Conclusions: Most patients with uterine leiomyoma are asymptomatic and acute complications are rare. In ICLM clinical manifestations are related to heart failure and flow obstruction. Because of the severity of the condition and the curative potential of treatment, surgery is morbid but highly recommended. The use of CPB with WBC improved the postoperative period and increased the patient’s quality of life

Effects of unilateral stereotactic posterior striatotomy on harmaline-induced tremor in rats

Although long known and the most prevalent movement disorder, pathophysiology of essential tremor (ET) remains controversial. the most accepted hypothesis is that it is caused by a dysfunction of the olivocerebellar system. Vilela Filho et al. [2001; Stereotact Funct Neurosurg 77:149-150], however, reported a patient with unilateral hand ET that was completely relieved after a stroke restricted to the contralateral posterior putamen and suggested that ET could be the clinical manifestation of posterior putamen hyperactivity. the present study was designed to evaluate this hypothesis in the most often used model of ET, harmaline-induced tremor in rats. Fifty-four male Wistar rats were randomly distributed into three groups: experimental (EG), surgical control (SCG), and pharmacological control (PCG) groups. EG animals underwent stereotactic unilateral posterior striatotomy. SCG rats underwent sham lesion at the same target. PCG served exclusively as controls for harmaline effects. All animals received, postoperatively, intraperitoneal harmaline, and the induced tremor was video-recorded for later evaluation by a blind observer. Thirteen animals were excluded from the study. Limb tremor was reduced ipsilaterally to the operation in 20 of 21 rats of EG and in two of nine of SCG, being asymmetric in one of 10 of PCG rats. Comparisons between EG x SCG and EG x PCG were statistically significant, but not between SCG x PCG. Limb tremor reduction was greater in anterior than in posterior paws. Lateral lesions yielded better results than medial lesions. These results suggest that the posterior striatum is involved with harmaline-induced tremor in rats and support the hypothesis presented. (c) 2013 Wiley Periodicals, Inc.Univ Fed Goias, Sch Med, Div Neurosurg, Goiania, Go, BrazilUniversidade Federal de São Paulo, Sch Med, Dept Neurosurg, São Paulo, BrazilPontifical Catholic Univ Goias, Sch Med, Dept Neurosci, Goiania, Go, BrazilGoiania Neurol Inst, Goiania, Go, BrazilUniversidade Federal de São Paulo, Sch Med, Dept Neurosurg, São Paulo, BrazilWeb of Scienc